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Research Article
Pathogenesis and Sequels
of Septic Arthritis of Hip in
Children
Balaji Zacharia* and Dhiyaneswaran Subramanian
Department of Orthopedics, Government Medical College, India
Abstract
Septic arthritis of hip joint is a relatively common infection in neonates and infants.
The most common organism causing it is gram positive cocci. High index of suspicion is
necessary for the diagnosis. Early diagnosis and prompt treatment can prevent long
term complications. Our objective is to describe the pathogenesis and sequels of septic
arthritis of hip in children of various ages.
INTRODUCTION
Septic arthritis most commonly affects hip joint. It is more
commonly seen in neonates, infants and young children [1]. The
most common route of infection is haematogenous [1-4]. It can
also occur as a direct extension of proximal femur osteomyelitis
since proximal metaphysis of femur is intra-articular. Exogenous
infection can occur via arthrotomy [1]. Most of the infections
are caused by staphylococcus aureus, group B streptococcus,
haemophilus influenza [1,5-8]. MRSA infection prevalence has
increased with the continuously increasing amount of antibiotic
resistance which also associated with more complications, longer
duration of antibiotics, and increased mortality [9]. Rarely,
organisms like pnemococci, gonocococci and Candida albicans
also cause septic arthritis [1,6]. Primary focus of infection is the
genitourinary tract, gastrointestinal tract, respiratory tract or in
the ENT area in most children [1,10,11]. In neonates and young
infants umbilical vein catheterisation, femoral venepuncture
can be the source of infection [1,9]. Diagnosing septic arthritis
in children is not a big deal but sometime may be confusing.
The differential diagnosis that should be considered are Aseptic
synovitis of the hip, Viral arthritides, Osteomyelitis, Juvenile
rheumatoid arthritis, Legg-Calve-Perthes disease, Lyme disease
(borreliosis), Slipped capital femoral epiphysis, Reactive arthritis
and Sickle cell anemia [12].
PATHOGENESIS
The infecting organism produces infection in the synovium.
Bacteria will be deposited in the sub synovial plexus leading
to synovial inflammation. Synovial fluid containing large
quantities of neutrophils and fibrin fill the joint cavity, which gets
distended. If proper treatment is given at this stage or the host
defence mechanism is able to contain the infection at this stage,
there will not be permanent joint damage. If infection continues
mesothelium lining the synovial membrane is destroyed and
Cite this article: Zacharia B, Subramanian D (2018) Pathogenesis and Sequels of Septic Arthritis of Hip in Children. JSM Bone and Joint Dis 2(1): 1014.
JSM Bone and Joint Diseases
*Corresponding author
Balaji Zacharia, Additional Professor, Department
Of Orthopedics, Government Medical College,
Kozhikkode, Kerala, India, PIN-673008; Email:
Submitted: 12 March 2018
Accepted: 05 April 2018
Published: 07 April 2018
Copyright
© 2018 Zacharia et al.
OPEN ACCESS
replaced by granulation tissue. As a result pannus formation and
articular cartilage damage can occur. Subsequently growth plate
damage or dislocation of joint, avascular necrosis with bony or
fibrous ankylosis can occur [13-16].
The vascular tamponade produced by increased intra-
articular pressure is the main cause of avascular necrosis of
capital femoral epiphysis. Doud et al. (1993), showed Meta
physeal osteomyelitis, producing subperiosteal abscess in the
poster superior aspect of the femoral neck, can occlude the
retinacular vessels leading to avascular necrosis.
The proteolytic enzymes released during the breakdown
of neutrophils can destroy the articular cartilage. It occurs
maximally at the points of contact between the opposing areas,
especially in hip joints. The glycosaminoglycan breakdown can
occur due to collagenase produced from synovial lining cells. The
enzyme plasmin is produced by the activation of plasminogen
in the blood. Plasminogen activation is by the streptokinase
and staphylokinase released by the organism. Plasmin causes
break down of protein – chondroitin sulphate complex of the
cartilage. Lastly, the release of acid and neutral proteases from
chondrocytes, when stimulated by bacterial lipopolysaccharides
or by interleukin 1, is another reason for articular cartilage
damage. Both avascular necrosis and cartilage destruction can
lead to damage to the growth plate [15,16].
SEQUELS OF SEPTIC ARTHRITIS OF HIP
There are many sequels to the septic arthritis in childhood.
The sequels developed depend on the age of occurrence and
the delay in getting treatment [17]. In neonates and up to six
months of age, the proximal femoral epiphysis may not develop
and an untreated septic arthritis at this age can lead to complete
destruction of proximal femoral epiphysis leading to unstable hip
[18-21]. After the development of capital femoral epiphysis the
sequels can be a completely normal hip if diagnosed early and
 Zacharia et al. (2018)
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treated properly [22,23]. Sometimes, due to increased vascularity osteotomy. Coxabreva can be managed by trochanteric
there can be coxamagna [24]. Infection can lead to physeal growth epiphyseodesis. Pseudarthrosis may require bone grafting with
arrest which can lead to shortening of femoral neck coxabreva, or without osteotomy [26,27,30-32].
shortening of the femur there by limb length discrepancy and/
Pathological dislocation can be reduced. Sometimes femoral
or abnormal shape of the proximal femur resulting in breaking varus rotational osteotomy or salter or chairi osteotomy
of the femoral neck. Various deformities like coxa vara, coxa is helpful in reducing the pathological dislocation. Rarely,
valga can develop as sequels [25,26]. Pseudarthrosis of the stabilisation procedures like Schanz pelvic support osteotomy,
neck of femur can occur associated with coxa vara [23]. In older is done. Colonna greater trochanteric arthroplasty by placing the
children, the main sequel is pathological dislocation. The head trochanteric apophysis into the acetabulum and distal transfer
in a dislocated hip can be either normal or avascular. Rarely, of abductors into the shaft for improving the abductor muscle
there can be dislocation of a sequestrated femoral head. In older function. This osteotomy is followed by a varus osteotomy at the
children untreated septic arthritis of hip can lead to stiff hip due subtrochanteric region later [33,34]. A sound bony ankylosis in
to bony ankyloses [20,27,28]. functional position can be accepted, where as a sound ankylosis
The treatment of the sequelae of septic arthritis of hip in non functional position requires a femoral osteotomy to make
needs to be delayed. There is high chance for remodelling, due it in to a functional position [31,32]. Limb length discrepency can
be treated by epiphyseodesis of the opposite limb or lengthening
to growth of some of the minor deformities getting corrected
of ipsilateral limb at appropriate age.
by remodelling. The shape and vascularity of femoral head and
neck are better known after remodelling. There is chance of CONCLUSION
reactivation of infection if interventions are done early. Besides,
the strength and quality of bone may improve over time [26]. Choi Acute septic arthritis of hip is a relatively common osteo-
et al., described a classification for the sequels of septic arthritis
in neonate hip joint following evaluation of 34 children who had
septic arthritis before the age of one [28] (Figure 1).
Type I: This group consisted of those patients with a normal
radiographic appearance (Ia), and those with evidence of
avascular necrosis.
1a-Normal radiograph
1b-Avascular necrosis
Type II: Involvement of the epiphysis, physis, and metaphysis:
This type results from avascular necrosis, with or without
significant damage to the capital femoral physis.
2a-Coxabrevia
2b-Coxa vara/Coxavalga
Type III: Damage to the femoral neck.
3a-coxa vara, coxa valga, with or without excessive femoral
ante version or retroversion
3b-pseudarthrosis of the femoral neck
Type IV: Loss of the femoral head/neck
4a- segment of the femoral neck is preserved,
4b-no femoral neck remnant

TREATMENT PRINCIPLES
Treatment of septic arthritis ranges from a intravenous
antibiotics, simple joint aspiration under ultrasound guidance,
formal arthrotomy and arthroscopic lavage based on patients
general condition and surgeons preference. But once acute
condition is not managed properly, it will leads to sequlae which
are having poor outcome even at best hands [29].
A moderate degree of coxa magna, coxa vara of less than
10 degrees and valgum of 15 degree can be left alone. Coxa
magna with uncoverage of femoral head needs to be contained.
Deformities can be treated either by open or closed wedge
Figure 1 Diagrammatic representation of Choi et al., classification of hip septic
arthritis sequlae
Type I:   1A-Normal radiograph; 1B-Avascular necrosis
Type II: Involvement of the epiphysis, physis, and metaphysic: 2A-Coxabrevia;
2B-Coxa vara/Coxavalga
Type III: Damage to the femoral neck: 3A-coxa vara, coxa valga, with or without
excessive femoral anteversion or retroverion; 3B-pseudarthrosis of the femoral
neck
Type IV: Loss of the femoral head/neck: 4A- segment of the femoral neck is
preserved;4B-no femoral neck remnant.

JSM Bone and Joint Dis 2(1): 1014 (2018)

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articular problem in neonates and infants. It can produce many
sequels. The prevention of such complications is better than its
treatment. Early diagnosis and prompt treatment is the way to
prevent it.
CONFLICT OF INTEREST
We have no conflict of interest for this manuscript and we
have not accepted any financial assistance from within or outside
of our institution for collecting data, writing manuscript and for
its publications
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Cite this article
Zacharia B, Subramanian D (2018) Pathogenesis and Sequels of Septic Arthritis of Hip in Children. JSM Bone and Joint Dis 2(1): 1014.
JSM Bone and Joint Dis 2(1): 1014 (2018)
Zacharia et al. (2018)
Email:
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